Provider Demographics
NPI:1154555803
Name:ROUNTREE, HOLLY L (LICENSED DIETITIAN)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:L
Last Name:ROUNTREE
Suffix:
Gender:F
Credentials:LICENSED DIETITIAN
Other - Prefix:MS
Other - First Name:HOLLY
Other - Middle Name:L
Other - Last Name:ROUNTREE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENSED DIETITIAN
Mailing Address - Street 1:2501 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1735
Mailing Address - Country:US
Mailing Address - Phone:229-259-4630
Mailing Address - Fax:229-259-4925
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:229-259-4630
Practice Address - Fax:229-259-4925
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003205133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered